Form Fmla-Hr2a - Notice Of Eligibility And Rights And Responsibilities - State Of Connecticut Human Resources Page 2
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Reason for Leave:
Personal Medical Leave
Caregiver Leave
(for your
(care for family member in connection with her disability
own serious health condition):
period related to pregnancy and childbirth, or his or her organ or bone marrow
donation, or other serious health condition):
___ My own illness or injury
__ Spouse
___ Disability period related to my
__ Parent
pregnancy and childbirth
__ Parent-in-law (State FMLA only)
___ Organ donation
__ Child (under age 18 or age 18+ and incapable of self-care due to a
___ Bone marrow donation
disability)
Bonding Leave:
Military Family Leave
:
___ Birth of child
___ Qualifying Exigency arising out of the covered active duty of your
___ Adoption of child
spouse, parent, or son or daughter
___ Placement of foster child
___ Military Caregiver leave for your spouse, parent, son, daughter or
(Federal and state FMLA only)
next of kin who is a covered servicemember
___ Military Caregiver leave for your spouse, parent, son, daughter or
next of kin who is a covered veteran (Federal FMLA only)
Federal FMLA:
To be eligible, an employee must have worked for the employer for at least 12 months, have worked at least 1,250 hours
in the 12 months preceding the leave, and worked at a site with at least 50 employees within 75 miles.
_________ You are eligible for federal FMLA Leave (See Part B and C)
_________ You are not eligible for federal FMLA leave because:
(
only one reason need be checked, although you may not be eligible for other reasons)
____ You have not met the federal FMLA 12-month length of service requirement. (As of the first date of
requested leave, you will have worked approximately __________months towards this requirement.)
_____ You have not met the federal FMLA 1,250 hours-worked requirement. (As of the first date of
requested leave, you will have worked approximately __________hours towards this requirement.)
____ You do not work and/or report to a site with 50 or more employees within 75-miles.
If you have any questions, contact ________________________________________ or view the FMLA poster located in
______________________________________________.
State Family/Medical Leave (C.G.S. 31-51kk):
_________ You are eligible for state FMLA Leave under C.G.S. 31-51kk. (See Parts B & C)
_________ You are not eligible for state FMLA leave under C.G.S. 31-51kk because:
(
only one reason need be checked, although you may not be eligible for other reasons)
____ You have not met the state FMLA 12-month length of service requirement. (As of the first date of
requested leave, you will have worked approximately __________months towards this requirement.
_____ You have not met the state FMLA 1,000 hours-worked requirement. (As of the first date of
requested leave, you will have worked approximately __________hours towards this requirement.
This form provided by the Department of Administrative Services
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